Indications for Shoulder Instability Surgery Anthony Miniaci M.D. - PowerPoint PPT Presentation

Indications for Shoulder Instability Surgery Anthony Miniaci M.D. FRCSC Professor of Surgery Cleveland Clinic Sports Health

Indications for Shoulder Instability Surgery Considerations  Instability classification  Natural history  Patient demographics-age, activity level, occupation, associated morbidities  Associated pathology  Prior treatments

Instability Classification: Spectrum  Unidirectional  “Classic” MDI  More surgery on “MDI”  Multidirectional instability lacks definitions-”MDI” has grown?

Shoulder Instability Surgery…………………………..Rehabilitation

Multidirectional Instability Lack of definitions 1. Patient population 2. Symptom definition 3. Surgical pathology

Multidirectional Instability Patient Population  Type of instability - voluntary, involuntary, Voluntary, positional, habitual Posterior,Traumatic  Direction- anterior, posterior,multi Anterior,  Injury pattern- none, Involuntary Atraumatic trauma, atraumatic (“born, torn, worn loose”) Multi, Involuntary,  Laxity- degree, focal vs. Atraumatic general, symmetry

Multidirectional Instability ! Laxity vs. Instability 2. Symptom Definition - pain, Instability or Both  Be sure looseness is - Instability- degree source of Sx (subluxation/dislocation)  Watch out for neck, - Apprehension, AC joint, etc. microinstability  Reproduce symptoms with subluxation

The MDI patient pathology- Imaging Studies Capsular laxity Rotator cuff tears Leakage of dye Labral Tears

Arthroscopic Capsular Shifts  Best results in milder forms of instability (subluxation), multidirectional laxity, anteroinferior instability with MD laxity  Good for patients with PAIN and laxity  Associated pathology best treated arthroscopically

What about Posterior Instability?  Dislocation  Fixed, Chronic  Recurrent  Subluxation  Traumatic  Micro  macro  Muscular- Voluntary  Scapula winging  Asymmetric muscular contraction  Positional- Involuntary

What about Posterior Instability?  Dislocation  Fixed, Chronic  Recurrent  Subluxation  Traumatic  Micro  macro  Muscular- Voluntary  Scapula winging  Asymmetric muscular contraction  Positional- Involuntary

What about Posterior Instability?  Dislocation  Fixed, Chronic  Recurrent  Subluxation  Traumatic  Micro  macro  Muscular- Voluntary  Scapula winging  Asymmetric muscular contraction  Positional- Involuntary

What about Posterior Dislocation ?

Posterior Dislocation- Arthroscopy Posterior Reverse Hill Sachs Lesion Glenoid

Posterior Instability/Subluxation  Repetitive microtrauma → posterior labral/ligamentous/capsular attenuation & tearing RPS – Recurrent Posterior Subluxation  Weightlifters, Linemen, tennis players, throwers, swimmer  Present with vague and diffuse posterior shoulder pain  Not typical to have recurrent dislocations  Pathoanatomy  posterior labrum, post capsule and posterior part of IGHL

Treatment Non operative  Rehabilitation, biofeedback, proprioceptive training  Cuff, deltoid, periscapular strengthening Surgical  Several options exist – arthroscopic/open capsulolabral reconstruction  Arthroscopic labral repair  Anatomic, minimally invasive, effective

Anterior Instability Epidemiology  Most common  Bimodal distribution  2 nd & 6 th decades  96% result from traumatic event  Overall incidence 1.7%  ~3 times incidence in males  Recurrent Shoulder Instability  Age-related recurrence following traumatic anterior instability  < 20 years old – 66-94%  20 to 40 years old – 40-74%  > 40 years old – 10%- ROTATOR CUFF tears Rowe et al., ‘56; Hovelius et al. ‘82

Recurrent Instability Associated pathology Osteoarthritis  Hovelius JSES ’ 09  Nonoperative tx with 1 more recurrence had more arthropathy  Buscayret AJSM ‘04  number of dislocations linked to risk for postop OA  Ogawa AJSM ‘10  5-20 yr f/u study of 167 open Bankarts evaluated with pre and postop CT  Postop OA correlates with increased number of instability events

• 127 patients; diagnostic arthroscopy, x-rays (AP, Glenoid, West Point), MRI Arthroscopy

Anterior Shoulder Instability Surgical Pathology  Labral tears  Capsular redundancy Unrecognized Pathology  Capsular Deficiencies/Avulsions  Labral pathology/ALPSA  Subscapularis tears- Open  BONE LOSS  Glenoid erosion or fractures(Bankart)  Hill-Sachs defects

Treatment options Glenoid Bone Loss Humeral Bone Loss 1. Bristow /Latarjet 1. Remplissage 2. Bone Graft- auto/allo 2. Decreased ER 3. Arthroplasty

Glenoid Bone Loss  <20% may treat arthroscopically/ soft tissue/open  Larger defect requires open fixation if bone stock adequate  Quantify with 3D CT  Consider combined effect of a humeral defect- treat smaller lesions Provencher et. al. JBJS, 2010 Bois, Jones, Miniaci et. al. AJSM, 2012

Glenoid Bone Loss  <20% may treat arthroscopically/ soft tissue/open  Larger defect requires open fixation if bone stock adequate  Quantify with 3D CT  Consider combined effect of a humeral defect- treat smaller lesions Provencher et. al. JBJS, 2010 Bois, Jones, Miniaci et. al. AJSM, 2012

What about the Hill Sachs ?

Hill Sachs  >25-30% Humeral Head must be addressed  Remplissage  French for “to fill”  Infraspinatus tucked into defect  Probably not enough when defect is >25% Provencher et al., JAAOS, 2012

Hill Sachs  >25-30% Humeral Head must be addressed  Remplissage  French for “to fill”  Infraspinatus tucked into defect  Probably not enough when defect is >25% Provencher et al., JAAOS, 2012

2013 Anatomic Reconstruction Options  Matched Allograft  Autogenous Iliac crest Autograft  Focal Resurfacing Option  Both studies with reported 0% redislocation  Preservation of motion!!

Combined Humeral Head and Glenoid Reconstruction

Shoulder Instability Surgery Summary  Know your patient  Demographics, activity etc  Know the pathology  Type of instability  Associated pathology  Know the natural history

Anthony Miniaci M.D. FRCSC Professor of Surgery Cleveland Clinic